Neurological Disorders

We report on 2 cases of Neurosarciodosis, it is a rare disease, primary care physicians and neurologists have very limited exposure to this pathology, published data till date is limited to few case series and case reports. There is also lack of enough demographical data of this illness in different regions around the globe, similarly there is absence of definitive diagnostic criterion for neurosarcodosis, and so it is often misdiagnosed and overlooked by clinicians due to identical clinical findings in other pathologies. This paper will review the presentation of two case reports and also highlight atypical presentations of this pathology that could potentially an aid to literature till date

A novel sonified Neurofeedback management therapy for children diagnosed with Autism Spectrum Disorder (ASD) is explored and tested. ASD is a condition in children which effects their social interaction, language and communication and behaviours. Literature suggests that people diagnosed with ASD tend to have higher levels of Delta (δ) waves and less levels of Alpha (α) and Beta (β) waves in their brain activity. This paper studies how the use of sonified Neurofeedback produced by a two channel EEG device headband and the Brain Music System (BMS), can successfully suppress the δ waves while at the same time promote α and β waves. The two channel EEG device headband records EEG activity and the BMS converts the EEG activity into sonified binaural signals feeding them back to the user. Results recorded showed a relevant δ wave suppression clearly indicating that children subjected to this study made significant progress in managing symptoms associated with ASD. This was also confirmed by feedback from the parents of the respective subjects.

Botulinum toxin (BoTx) is well known as a popular drug of choice for spasticity relief. Recent research shows that the toxin has synaptic competitive-learning (SCL) restoring plasticity properties acting at peripheral and central nervous sensory-motor centers. In the intact brain, SCL is naturally-endowed, that controls-regulates all learn-register-recallexecute (motor) functions, and memory storage functions during development and throughout adult life. In spinal cord injury (SCI), hemiplegic cerebral palsy (HCP), and stroke, there is partial/complete cessation of all SCL mechanisms in those injured and denervated centers. The denervated synaptic fields soon become reinnervated by spontaneous growths of aberrant, maladaptive synaptic weights. The massive loss of neurons in the injured site/s and the resultant synaptic weights (=defined as learned motor experiences stored as memory weights) distortions in the denervated centers cause spasticity and sensory-motor paralysis. It is known that BoTx spasticity relieving effects in single, isolated muscle/s are short-lived. However, clinical studies indicate that when given to multiple spastic muscles in serial/ repeats, BoTx generates significant recovery. Basic science studies show that BoTx generates neosynaptogenesis at motorendplates, on spinal motoneurons and motor cortex. It reinstalls the three cardinal courses of SCL viz. initial redundant connections, activity-dependent, competition-based pruning-selection refinement of connections at these sites. This paper presents i) a cognitive systems perspective of spasticity and motor paralysis, ii) a low-dose, multi-muscles BoTx treatment protocol designed to keep its paralyzing effects minimized, while prolong its SCL duration in order to initiate and consolidate long-lasting motor recovery in these disorders.

Previous research from our lab has shown that when using a rodent model of ischemic stroke (permanent middle cerebral artery occlusion), mild sensory stimulation, when delivered within two hours of ischemic onset, completely protects the cortex from impending ischemic stroke damage when assessed 24 hours post-occlusion. However, the long-term stability of this protection remains unclear. Using intrinsic signal optical imaging for assessment of cortical function, laser speckle imaging for assessment of blood flow, a battery of behavioral tests and cresyl violet for histological assessment, the present study examined whether this protection was long-lasting. When assessed 4 months post-occlusion (this length of time being equivalent to 10-15 years in humans), rats receiving sensory stimulation treatment immediately after ischemic onset exhibit normal neuronal and vascular function, and they are behaviorally and histologically equivalent to healthy controls (surgical shams). Thus, the complete neuroprotection due to cortical activation via sensory stimulation remains stable with time. These findings add support to the translational potential of this sensory stimulation-based treatment.

Objective: Endoscopical procedures in the ventricles for the treatment of hydrocephalus or removal of solid tumors are commonly used in neurosurgery. Even a minimal blood amount leads to a complete loss of visibility (“red out”) endangering the patient. To enable coagulation of a bleeding vessel in “red-out” we developed and tested the VNSoftware- System.

Methods: An optical-positioning-system (OPS) receives signals from 3 infrared Light-Emitting-Diodes (LED) on the endoscope and digitalized endoscopic images are created reproducing the real position of the endoscope. An imaging software correlates the transmitted images (max 8/sec) with the positional data. The virtual images of the VN-Software are available next to the real image of the endoscope-camera. In cases of bleeding a “red-out-sensor” activates the “virtual mode” and the surgeon can navigate the endoscope based on the positional coordinates and the saved images of the software program. The bleeding vessel can be localized and coagulated.

Results: When the target region included a radius of 2 mm around the epicenter the success rate was 96.9%. Only in 3.1% of the experiments the target was missed of more than 2 mm. The mean precision in all experiments was 0.81 mm around the epicenter. The mean time of target finding and coagulation was 48.23 sec.

Conclusion: Localizing a bleeding vessel in a “red-out” condition with the VN-Software is reliable and will improve endoscopical safety in removal of highly vascularised tissue. The VN-software showed a high precision-rate in finding a given target in “red-out” conditions.

Background: Acute stroke teams are challenged by IV-tPA decision making in patients with acute neurological symptoms when the diagnosis is unclear. The purpose of this study was to evaluate the ability of the rapid Brain Attack Team (BAT) MRI in selecting patients for IV-tPA administration who present acutely to the emergency room with strokelike symptoms and an unclear diagnosis.

Methods: Consecutive patients were identified who presented within 4.5 hours of onset of stroke-like symptoms and considered for treatment with IV-tPA. When the diagnosis was not clear, a 9-minute BAT MRI was obtained. Stroke risk factors and NIH stroke scale obtained on presentation were compared between patients in whom BAT MRI was obtained and those in whom BAT MRI was not obtained. Similarly, comparisons were made between patients in whom BAT MRI detected abnormalities and those in whom BAT MRI did not detect abnormalities. BAT MRIs were analyzed to determine if radiological findings impacted clinical management and discharge diagnosis.

Results: In a 30-month period, 432 patients presenting with acute stroke-like symptoms were identified. Of these patients, 82 received BAT MRI. Patients receiving BAT MRI were younger, more likely to be smokers, and less likely to be selected for IV-tPA administration compared to those in whom a more definitive diagnosis of stroke precluded a BAT MRI. Of the 82 BAT MRIs, 25 were read as positive for acute ischemia. The patients with acute ischemia on BAT MRI were older, more likely to be males, have a history of hypercholesterolemia and atrial fibrillation, and more likely to be selected for IV-tPA administration compared to those with a negative BAT MRI. Of the 57 BAT MRIs read as negative for acute ischemia or hemorrhage, discharge diagnoses included TIA, MRI negative stroke, conversion/functional disorder, and multiple other illnesses.

Conclusion: In patients with acute stroke-like symptoms, BAT MRI may be used to confirm acute ischemic stroke, exclude stroke mimics, and assess candidacy for IV-tPA.

Spinal cord injury often results into severe neurological deficits. Currently, there is no treatment available which can reverse the damage. Cell transplantation is a novel treatment strategy which has shown promising results in animal models of spinal cord injury. We administered fifty six chronic cervical spinal cord injury patients with autologous bone marrow mononuclear cells, intrathecally. As a part of the protocol, all the patients also underwent rehabilitation along with cell transplantation. On a mean follow up of 2 years ± 1 month, symptoms such as trunk stability, sitting balance, trunk muscle strength, upper limb strength, standing balance, deep touch sensation, bladder sensation, spasticity and walking balance demonstrated improvements. On performing McNemars test, a significant association was found between the improvements in these symptoms and the intervention. The improvement in Functional Independence Measure (FIM) scores was statistically significant using Wilcoxon Signed Rank test. A detailed analysis of factors such as age, cause of injury, chronicity of injury and rehabilitation before the intervention was performed. Here, we also compare this chronic cervical SCI group with chronic thoracolumbar SCI patients of our previous study. Though functional improvements were observed at greater extent in chronic thoracolumbar SCI group, the results in chronic cervical SCI group were also significant. Cell transplantation may promote neurofunctional recovery and improve the quality of life of the patients with chronic cervical spinal cord injury.

Background: Aortic Atheroma (AoA) is an independent risk factor for new and recurrent stroke. AoA ulceration and mobility are associated with an increased risk for brain embolism. Transesophageal echocardiography (TEE) is the gold standard for detection and measurement of AoA in stroke/TIA patients. Cardiovascular MRI (cMRI) could be an alternative, non-invasive imaging modality for stroke/TIA patients. The objective of this study was to assess the accuracy and correlation of AoA detected and measured by cMRI versus TEE in patients with recent stroke/TIA.

Methods and results: Twenty-two stroke/TIA patients undergoing TEE as a part of their stroke workup consented to a protocol-mandated cMRI performed on a 1.5 T magnet. The protocol included an axial non-breathhold EKGgated dual-echo spin echo MRI of the thoracic aorta (TR/TE1/TE2=900/29/69) and a contrast-enhanced breathhold 3D gradient-echo image of the thorax (flip/TR/TE=12/4.0/1.71). Maximum plaque thickness, ulceration (≥ 2 mm) and mobility of AoA were assessed in the proximal (ascending and proximal arch) and distal (distal arch and descending) segments of thoracic aorta by a cardiologist to interpret the TEE and a radiologist to interpret the cMRI. There was good correlation between cMRI and TEE in measurement of plaque thickness in the proximal segments (R=0.73, p<0.0001) and the distal segments (R=0.81, p<0.0001) of the aortic arch (AA). cMRI had a high degree of accuracy in detecting measurable AoA (≥ 1 mm) in the proximal segments (sensitivity 90%, specificity 100%), as well as the distal segments (sensitivity 67%, specificity 100%). cMRI also had a high degree of accuracy in detecting significant AoA (≥ 4 mm) in proximal segments (sensitivity 71%, specificity 93%), as well as distal segments (sensitivity 71%, specificity 100%).

Conclusion: The study showed a high degree of accuracy and correlation of AoA detected and measured by cMRI as compared to TEE in patients with recent stroke/TIA. This technique has limitations in detection of AoA ulceration, and protocols assessing AoA mobility need to be developed.